The managed care line at AHF is responsible for finding ways to reduce the cost of providing health care to patients. This week, we speak to three of our managed care team members about what they do, how they do it, and why they’re passionate about their work and the AHF mission.
Putting the “Care” in Managed Care
Perspectives from our managed care team at AHF
GUEST BIO:
Julio Roberto is a medical social worker out of the Fort Lauderdale bureau.
Karen Haughey is a registered nurse and Vice President of Managed Care, also based in Fort Lauderdale.
Rebeca Rubio is the National Director of Managed Care Operations and Program Development based in Los Angeles.
CORE TOPICS + DETAILS:
[2:13] - Defining Managed Care at AHF
What they do and what it means
Managed care is a far-reaching term at AHF, including everything from providing support for people without a healthcare plan to offering integrated medication management and case management regardless of insurance status.
The overall effect is greater patient care and satisfaction among a group of people who often come into AHF frightened and with no idea how to begin their journey. Managed care provides them with empathy and direction.
[8:04] - Day-to-Day with Patients
What managed care means on the ground
The managed care team’s goal is to soon have a representative available to speak to every single person who walks into an AHF healthcare center. This isn’t currently the norm nationwide among big box insurance companies. In AHF’s vision, everybody will get a care manager and a full team to ensure they get what they need, when they need it— all with a focus on empathy.
[12:20] - Working with Other AHF Business Lines
A culture of collaboration
Managed care works with nearly every line of business at the organization, from finance and IT to the healthcare centers themselves. For example, they work directly with healthcare centers as it relates to patients receiving bills or claims on the health insurance side. If a patient receives a bill, they can communicate with managed care about getting it processed for payment— and ensuring they don’t get surprise bills.
[17:31] - Final Thoughts
What AHF members and patients should know about the managed care team
Karen shares a common refrain she shares at managed care:
“Managed care dances on the edge of all of our contracts, and our regulations, and the mission. When we fall, we always fall on the side of the mission."
The biggest takeaway is that managed care exists to make the mission of AHF— patient health— their personal mission. “When we collaborate on that, or put that together with the mission of AHF, everyone benefits.”
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Hello and welcome to the After Hours podcast. I'm your host, Lauren Hogan, serving as your liaison to take you through this journey, to learn more about AIDS Healthcare Foundation. Before we start the show, please make sure to remember to check out the show notes, so you can follow along. Now, let's get started.
Hello everyone, and welcome back to another episode of the After Hours podcast. As always, I'm your host, Lauren Hogan, and today, we get to talk with a few folks that are part of a very important business line here at AHF, our managed care team. I'm so excited to have you guys with us today, so you guys can give us some insights, all of the amazing things that you do for AHF. Let's get started. Just quickly introduce yourself, your role, and how long you've been with AHF. Julio, I'll start with you.
Julio Roberto:
Hi, my name is Julio Roberto. I am a medical social worker out of the Fort Lauderdale, Florida, office, headquarters, or bureau. I have been on and off with AHF since 2016, until currently. I left for a little while, the grass wasn't greener on the other side, and AHF was gracious enough to bring me back aboard. I'm very grateful for that.
Lauren Hogan:
Awesome. Karen?
Karen Haughey:
Hi everybody, my name is Karen Haughey. I'm an RN, and I'm the vice president of managed care, based in Fort Lauderdale.
Lauren Hogan:
Rebecca?
Rebecca Rubio:
Hello everyone, my name is Rebecca Rubio. I am the national director of managed care operations and program development, based in Los Angeles. I've been with the company since 2016.
Lauren Hogan:
Awesome. Basic question, what does managed care mean? What is it? What do you guys do? I feel like you guys are our unsung heroes in some ways. Just let us know all things managed care. What do you guys do, and what does it mean for the organization?
Karen Haughey:
I'll take that one, Lauren. First of all, managed care is one of those, "What does that mean" words. We're always defining ourselves. We have health plans, we have Ryan White, Ryan White is the payer of last resort for folks who are positive, and do not have a healthcare plan. We have an integrated medication management care management team that works directly with the pharmacy. Our brand new program is the AHF Care Management, which is, any patient who comes to AHF, regardless of who their insurer is, we offer case management to them.
Lauren Hogan:
How does this directly affect the organization, in terms of our patients?
Karen Haughey:
It has a whole lot to do with patient satisfaction. A lot of our folks come in, especially first time people who just had no idea that now they were going to begin this journey, they're frightened. They need help. When linkage hands them off, they hand them off to care management, where we follow them both medically, and for the social determinants of health. I could let Julio speak more about that, because that is definitely what he does. In terms of the plans, we're a special needs plan. What that means is, folks who are positive have a Medicare plan specifically for them. They also have a Medi-Cal plan in California, which is run by the regulations of the state, and the Medicare plan, PHP, is run by the feds. Rebecca is very familiar with the regulations, both statewide and fed wise. Whichever direction you want to take the questions in, whether it's patients and social determinants of health, or the regs, I'll leave it to them.
Lauren Hogan:
Please go ahead Julio.
Julio Roberto:
As I said before, I'm a medical social worker. I am one of two that we have in the Fort Lauderdale office. I deal with the Miami-Dade County area. The other social worker handles Broward, which is where the headquarters are, the office is. Basically, my job is to work together with the nurse care management team, the care coordination team, and the management team of the office, to determine what issues are causing a member problems within the community, be it housing, being food insecurity, financial issues. Once we determine that, I work with the nurse care managers to assist them with those programs, and bring them a little relief. We all know that a lot of those things affect people psycho-socially, and when their mental health isn't there, they don't tend to take care of themselves physically, and handle their medicines and their medical care properly. My job is basically to make sure that where they live, what they eat, and the money they have in the bank is sufficient for them to be able to be comfortable enough to work on their medical needs, together with the nurse care management team.
Lauren Hogan:
Rebecca, do you mind telling us the insurance end of how this is all being affected? You guys talked about Medi-Cal, and Medicare, and Ryan White. How does insurance factor into what you guys do, in relation to our patients?
Rebecca Rubio:
With our motto being, "We provide care regardless of ability to pay," years ago we identified that there was a need for a special needs plan, to service our patients living positive. Developing the Medicare and Medi-Cal line of business provides our patients a specialized health system to address their specific needs in the community. When we think about Medicare or Medi-Cal as a whole, there are a lot of regulatory requirements that we have to meet, whether that be through audits, or just making sure we meet all the quality measures that are expected of a health plan. AHF is unique in that we have our healthcare centers that are extremely integrated with our health plans, and our providers are infectious disease specialists. We try to build provider specialty networks that are aware of our patients, and are sensitive to their needs, and trying to get them the best care possible.
We also provide our member engagement/member services department, which interacts with the healthcare centers and with our members directly. We also do the administrative side of healthcare insurance, which would be processing claims, building the network, having quality metrics in place, to ensure that our patients are receiving the best care possible. A lot of that is regulatory jargon that you see within Medicare and Medi-Cal plans, but we execute that working along with the healthcare centers, the finance department, all of the different branches of AHF. We're integrated, and doing that administrative side, to make sure our patients are getting what they need.
Lauren Hogan:
You actually alluded a bit to my next question, and that is, for our managed care staff that's actually onsite at healthcare centers, for instance, what assistance do you guys provide patients in person? Do all patients have the opportunity to meet with managed care staff?
Karen Haughey:
I'll take that. Yeah, absolutely. If they are part of the Medi-Cal or the Medicare plans, PHP or PH Florida, California, and PHC California, we actually try to meet the RNs, and Julio would meet them where it's most convenient, whether that's at an appointment, at the HCC, whether it's in a parking lot, wherever it needs to be, we meet them there. For the Ryan White program, those care managers are embedded in all of our healthcare centers where we have Ryan White grants. I believe that number is climbing every day. I think there's only about a handful where we don't have care management through Ryan White. To pick up those folks who don't have Ryan White, or are not in a PHP or PHC, the AHF care management program... we're just starting that program.
I like to say it's newborn, and the baby's learning to crawl. We have community health workers right now at Westside, North Point, and Hollywood. The goal and the expectation is to move that program nationwide, in every one of our healthcare centers. Probably by this time next year Lauren, if that question was asked, it there would be someone from managed care there to talk to every single person who walks into a healthcare center. That's the ultimate goal.
Lauren Hogan:
Let me ask this, too. I feel like AHF as an organization is unique in a lot of ways, in terms of the type of specialty care that we provide. Let's say, in the next year, that our patients would actually have this direct access to managed care on site, how is that different or special for a potential patient that may be going to another healthcare company for care? How is that different? Is that the norm?
Karen Haughey:
It's not the norm. We are set apart by the fact that we are a special needs plan. Most of the big box insurance companies, the ones we're familiar with, Blue Cross, Aetna, United, you may get a care manager for 30 days when something catastrophic happens. Not all the time, you have to meet the criteria. In our plan, everybody who comes into our healthcare plans gets a care manager. They actually get a team. They get the RN care manager, they get Julio, the medical social worker, they get a care coordinator, and a community health worker. That's what sets us apart from everyone else.
Julio Roberto:
To piggyback on that, it's funny, because my director Tiffany, and our manager and assistant director, I brought up a term a while back that I consider us a boutique plan. You're walking in somewhere, and you have a concierge service, and you have these specialties that other plans don't have. I've been with the big box plans, I've worked as an employee for them, and you don't see them having care coordination the way that we do, or having a social worker available. The nurse can call me, message me, let me know on a Friday at 3:00 in the afternoon, "This gentleman, they're going to cut off his light next week. Can you help them out?"
The big box plans, what you'll get is a voicemail. Most of us have cell phones, and we answer our calls personally. These types of items are things that you don't see at these bigger plans, and I see it that way. We're a more catered, fine tuned plan for the type of member that we deal with, and their illness.
Lauren Hogan:
I think that's so important to highlight, thank you for doing that. The next thing I wanted to dive into, can you guys describe how you guys work with other business lines? I feel like people sometimes don't understand the fact of how integral managed care is in the line of connecting a patient to care. Can you describe how you guys work with other business lines, whether it's sales reps, or somebody from pharmacy, or our testing team? Can you just talk about those relationships?
Karen Haughey:
Rebecca, do you want to take that one?
Rebecca Rubio:
I can speak from an administrative side. For the detail on the clinical side, of the direct patient connecting into care, I would punt that back to Karen and Julio, to get the specifics. From an administrative perspective, we work with pretty much every line of business at the organization, from finance, IT, the healthcare centers directly. For example, we work directly with the healthcare centers as it relates to patients receiving bills, or claims is what we call it, on the health insurance side. At times, if a patient were to receive a bill, they would communicate with us, because potentially, we should have processed it for payment, and making sure that a patient doesn't get what we would call a surprise bill. They went and got services at our healthcare center, if they're in our primary, in our PHP and PHC lines of business, or if they're a patient in Ryan White, we would process those claims so it wouldn't come out of the member's pocket, or the patient's pocket.
Administratively, we work closely with the healthcare centers around those items, and around quality of the patient's care. If a patient had an issue or a complaint at the healthcare center level, or with their specialist office, or just something that they were dissatisfied about, we receive those communications directly, and process them, and work with the divisions that we need to in order to resolve the patient's issue, and improve the satisfaction of the member as well. Also, from a technology perspective, we work a lot with systems, from a regulatory perspective, or just from an improved patient engagement and satisfaction perspective. We are often working with IT to find the latest and greatest, and implement it not only for our member, or to improve operations, to ease workload on staff as well.
Karen Haughey:
From the clinical side of that, the conversations, and conferences, and collaborations that the nurses and the medical social workers have with the primary care providers at each of the healthcare centers is essential. Sometimes, white coat syndrome happens to all of us. We walk in there, Doc says, "Hey, do you have any questions?"
You say, "No, I'm fine." Our job is to make sure those questions get asked and answered. Sometimes, we even accompany the patient into their appointment. If that's needed, we'll collaborate with the Doc first, and say, "Can we come in the office? The patient would like us to." There's never been a time when that hasn't happened. I spoke earlier about IMM, the integrated medication management program. That was one of the first collaborations between two big divisions, Pharmacy and managed care. They, meaning pharmacy, needed the care management piece in order for this program to work.
Donna Stidham, our chief of Managed Care, and Scott Carruthers, the chief of pharmacy, got together, and we collaborated to bring both what we do and what pharmacy does, so that all of our pharmacy patients also have this added benefit of a care manager. That we're really proud of, because that was one of the first ones we ever did where it was a true... I used to call it the marriage of pharmacy and managed care programs. It's probably going on seven or eight years now, it's been extremely successful.
In terms of the plans and Ryan White, the collaboration there between all members of both of those... it's easy when you're in the healthcare center, because we call them hallway conferences, hallway consultations. It could be very formal, as in, "Let's sit down and discuss patient A, B, C with the provider," or, it can be in the hallway, "Hey Doc, do you know that so and so just had this happen to them?" We set that picture. The collaboration there is very strong.
Lauren Hogan:
Great, thank you so much. We are at time, it goes by really fast. I do have one final question for you guys, and that is, what should employees know about the managed care team, and what should those outside of AHF know about your team?
Karen Haughey:
I have a saying, "Managed care dances on the edge of all of our contracts, and our regulations, and the mission. When we fall, we always fall on the side of the mission." Sometimes that gets us in trouble, but it's what we all know to be true. The biggest takeaway is that we are here to make the mission, our mission in managed care is your health, our mission. When we collaborate that, or put that together with the mission of AHF, it fits very nicely.
One of the other things I like to say is, we're the drain at the bottom of the sink. We try to make sure we catch everything. We are the filter. If someone in another department, or another division knows there's an issue with a patient, and they don't know what to do, they can pick up the phone and call anyone in managed care, and we'll get them to the right person, to get the right help.
Lauren Hogan:
Awesome. Julio, Rebecca, anything you guys want to add?
Julio Roberto:
Rebecca?
Rebecca Rubio:
I think Karen really summarized it well.
Julio Roberto:
From a ground perspective, being boots on the ground, to further talk about what Karen had said, we all work tirelessly every day, as a team, to work through issues or problems that we can try to resolve, to make a person be the healthiest them that they can be, be it socially or medically. We spend 90% of our day solving those issues, so that person has a fair shake at living the best life that they can live.
Lauren Hogan:
That's beautiful. Thank you so much.
Karen Haughey:
That's where we want to thank you, Lauren, because managed care is one of those words... I have a lot of things that I say. One of the things I say is, nobody grows up and says, "I want to work in managed care when I grow up," because it's one of those broad terms. Everybody knows what a pharmacy is, everybody knows what a healthcare center is, what finance is. When you say managed care, it's like, "What is that?" On behalf of managed care, thank you so much for allowing us to share our world with you.
Julio Roberto:
Thank you.
Lauren Hogan:
No, we appreciate it. Like I said, you guys, a lot of times, I feel like are our unsung heroes. It's only proper that we make sure that we highlight you guys, and thank you for all that you do for all of our patients. You are definitely the engine behind the mission, for sure. We appreciate you guys, and all your hard work.
Rebecca Rubio:
Thank you so much.
Karen Haughey:
Thank you.
Lauren Hogan:
Thank you all for joining another episode of the After Hours podcast, and we will see you next time.
Thank you so much for joining us. If you enjoyed this episode, and you'd like to help support the show, please subscribe, share it with your friends, like, post about it on social media, or leave a rating and review. Follow us on Instagram at after hours, and see you next time.